OR I G I N A L R E S E A R C H

Arm port vs chest port: a systematic review and

meta-analysisThis article was published in the following Dove Press journal:

Cancer Management and Research

Guanhua Li1,*

Yu Zhang2,*

Hongmin Ma3

Junmeng Zheng1

1Department of Cardiovascular Surgery,

Sun Yat-sen Memorial Hospital, Sun Yat-

sen University, Guangzhou, Guangdong

510120, People’s Republic of China;2Department of Pathology, The Second

Affiliated Hospital of Guangzhou

University of Chinese Medicine,

Guangdong Provincial Hospital of

Chinese Medicine, Guangzhou,

Guangdong 510120, People’s Republic of

China; 3Department of Surgery,

Guangzhou Women and Children’sMedical Center, Guangzhou, Guangdong

510623, People’s Republic of China

*These authors contributed equally to

this work

Background: Two prevailing, totally implantable venous access ports are routinely utilized

in oncology: chest port or arm port. This systematic review with meta-analysis

was conducted to compare safety and efficiency of the two techniques.

Methods: We performed evidence acquisition intensively from PubMed, Embase, and

Cochrane Library. Available comparative studies that evaluated both techniques were identi-

fied. The outcomes of interest included total complication events, procedure-related infec-

tions, thrombosis, intra-operative complications, mechanical complications, conversion rate,

early port removal, and operating time.

Results: Thirteen comparative studies including 3,896 patients (2,176 for chest ports, and

1,720 for arm ports) were identified. The present study showed that arm port was associated

with higher procedure conversion rate (2.51% in chest port group and 8.32% in arm port

group; odd ratios [OR] 0.27, 95% confidence interval [CI] 0.15-0.46; p<0.001), but lower

incidence of intra-operative complications (1.38% in chest port group and 0.41% in arm port

group; OR 2.38, 95% CI 1.07–5.29; p=0.03). There were no between-group differences with

respect to total complication events, procedure-related infections, thrombosis, mechanical

complications, early port removal, and operating time. Subgroup analysis of patients under

60 years revealed that no significant difference was detected in intra-operative events (1.19%

in chest port group and 0.02% in arm port group, OR 2.59, 95% CI 0.74–9.08; p<0.14),

indicating that age may be a risk factor for intra-operative events. Sensitivity analysis did not

change conclusions of all endpoints of interest.

Conclusion: Arm port is associated with higher procedure conversion rate, but lower incidence

of intra-operative complications, and age may be a risk factor for intra-operative events.

Keywords: chest port, arm port, total implantable venous access port, systematic review,

meta-analysis

IntroductionTotally implantable venous access ports (TIVAPs), a long-term indwelling infusion

system, was first introduced by Niederhuber in 1982.1 With the increasing use of

chemotherapeutic drugs in oncologic patients, TIVAP gains its popularity due to the

fact that this system enables long-term administration of chemotherapeutic agents,

attenuates the burden of chemotherapy, and thus greatly improves quality of life in

oncologic patients, meanwhile, this system preserves peripheral vessels and prevents

venous-related infections.2–4 Two prevailing approaches are routinely utilized in

oncology: chest ports or arm ports. Chest ports are most frequently implanted

under the guidence of ultrasonography, via internal jugular vein, external jungular

vein or subclavian vein puncture, while arm ports are placed through forearm veins

such as basilic vein, cephalic vein or brachial vein, either through percutaneous

Correspondence: Junmeng ZhengDepartment of Cardiovascular Surgery, SunYat-sen Memorial Hospital, Sun Yat-senUniversity, No.107 Yanjiang West Road,Guangzhou 510120, People’s Republic ofChinaTel +86 208 133 2603Fax +86 208 133 2853Email zhengjunmeng@126.com

Cancer Management and Research Dovepressopen access to scientific and medical research

Open Access Full Text Article

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and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the workyou hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. Forpermission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php).

http://doi.org/10.2147/CMAR.S205988

puncture or surgical cut-down, both generally showing

satisfactory results with respect to technical success and

low incidence of postprocedural complications.5,6

For years, the chest has been the most popular and

reliable access site of implantation for long-term indwelling

ports, however, chest ports might not be eligible for patients

undergoing radiotherapy with chest wall involvement, or

those with chest wall skin lesions, meanwhile, many female

patients experience perception of “foreign body”, “bra

inconvenience”, and discomfort when wearing safety belt

or bag strap. In 1993, an alternative arm port procedure was

introduced by surgeons at the School of Medicine, Yale

University.7 The arm ports have some unique advantages

compared with chest ports, such as no risk for hemothorax

or pneumothorax, lower incidence of arterial puncture,8

better cosmetic outcome,9 and more “bra convenience”.10

These advantages are especially beneficial to breast cancer

patients requiring radiotherapy, flap transferring for recon-

structive surgeries, as well as those patients with radioder-

matitis or compromised respiratory function.11

Nevertheless, the most significant disadvantage of arm

port implantation is high incidence of failure (technically

unsuccessful port placement), which is around 6.4%.12,13

Despite the wide application of TIVAPs, there is no

consensus whether one or the other access site of implanta-

tion for TIVAP is clinically superior. Although several stu-

dies that compared chest access and arm access had been

reported by various institutions, some of the results are con-

flicting and within small population of patients.14–16 In the

present study, we attempted to investigate and assemble the

most comprehensive clinical data currently available in

the literature to address a debatable issue: which approach,

the arm port or the chest port, is more clinically beneficial to

oncologic patients for the implantation of TIVAPs?

Evidence acquisitionClinical data search strategyThe present study was carried out according to the Meta-

analysis Of Observational Studies in Epidemiology

(MOOSE) recommendations and the Preferred Reporting

Items for Systematic Reviews and Meta-Analyses

(PRISMA) protocol.17,18 Systematic review registration was

not available. Literature search was executed in August 2018,

regardless of article types, regions or language of publication.

Eligible studies were primarily from on-line databases of

PubMed, Embase, and the Cochrane Library. Medical

Subject Headings (MeSH) terms, as well as their combinations

were manually searched via (Title/Abstract) as follows: basi-

lic/cephalic/brachial/subclavian/jugular AND totally implan-

table venous access port/totally implantable venous access

device/venous port/indwelling port, with “Related Articles”

function applied to expand the search results. Corresponding

author was contacted if additional information was required.

When the same group of authors published multiple but simi-

lar reports of studies, the most comprehensive or the most

recent result was taken into consideration.

Inclusion and exclusion criteriaInclusion criteria: 1) patients: patients who were diagnosed

with malignancies requiring long-term indwelling ports, or

those with gastrointestinal disorders requiring long-term

venous port for parenteral nutrition support; 2) intervention:

arm ports (basilic/cephalic/brachial vein insertion) vs chest

ports (subclavian or jugular vein insertion), regardless of

implantation methods, including surgical cut-down (peripheral

vein cut-down method through surgical approach) and percu-

taneous puncture (radiology-guided placement, ultrasound-

guided implantation, fluoroscopy-guided insertion, direct punc-

ture, and so forth); 3) study types: all randomized controlled

trials (RCTs), comparative studies available in the literature

including cohort and case control studies which compared

arm ports and chest ports were included; 4) outcomes: studies

quantitatively reporting at least one of the outcomes described

in the next section of this paper were included.

Exclusion criteria: 1) letters to the editor, editorials,

reviews, case reports, laboratory-based animal studies,

non-clinical studies, conference abstracts, and meta-

analysis papers; 2) studies that failed to clearly clarify

the outcomes of interest were excluded. If multiple access

sites of implantation were compared in a single study

(cephalic, jugular and subclavian vein), results of chest

port/arm port category were combined.

Data extractionTwo independent authors (YZ, GL) conducted data extraction.

Any discrepancy was resolved by discussion and consultation

with senior authors in this paper (HM and JZ). Data on clinical

characteristics (age, diagnosis), type of port, and technique

used (approach of insertion) were collected. Port-related com-

plications were classified into four categories: intra-operative

complications, infectious complications, thrombotic complica-

tions, and mechanical complications.19,20

The primary outcomes of interest were the incidences of

port-related complications from implantation to removal of

Li et al Dovepress

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DovePressCancer Management and Research 2019:116100

TIVAP. Intra-operative complications included arterial punc-

ture, hemothorax, and pneumothorax. Procedure-related

infections, composed of port-site infection and catheter-

related bloodstream infection, were diagnosed in accordance

with the latest guideline of the Infectious Diseases Society of

America.21 Procedure-related thrombotic complications

were identified as any mural thrombi formed from the port

catheter to the vessel lumen, giving rise to catheter occlusion,

regardless of the presence of symptoms.22 On the basis of

Clavien-Dindo classification of surgical complications,23

mechanical complications included port misfunctioning

(such as deficiency of infusion or catheter occlusion), cathe-

ter fracture (defined as physical damage to the catheter of the

port system), port dislocation (also named catheter migration

or malposition), pinch-off syndrome, and hemorrhage.

The second outcomes of interest were conversion to other

access site of placement, early port removal (port removal

before completion of treatment), and operating duration.

Quality assessmentEvaluation of RCT quality was subject to the Cochrane

Collaboration’s tool, through which risk of bias was

assessed based on Cochrane Handbook for Systematic

Reviews of Interventions.24 Judgment of overall risk of

bias for each included RCT was assessed as: low, moder-

ate, or high.24 RCTs with low risk of bias were regarded as

high quality. Quality of observational study was assessed

according to the Newcastle-Ottawa scale (NOS), consist-

ing of three aspects: patient selection, comparability of the

study groups, and assessment of outcome.25 A quality

score ≥8 points was regarded as high quality study.

Statistical analysisReview Manager 5.0 (Cochrane Collaboration, Oxford,

UK) was used for this systematic review with meta-

analysis. Weighted mean difference (WMD) was used to

compare continuous variables, while odd ratio (OR) was

employed to compare dichotomous variables. Ninety-five

percent confidence interval (CI) was applied to all data

throughout this study. When confronting with continuous

variable expressed as mean and range value, standard

deviation (SD) was converted as suggested by Hozo

et al.26

Chi-squared test was used for the evaluation of statis-

tical heterogeneity between studies, and significance level

was set at p=0.10. For quantitative assessment of hetero-

geneity, I2 statistic was used, and high heterogeneity level

was set at 75%.27 The random-effects model was applied if

between-study heterogeneity was high, in order to make

more conservative estimates,28 otherwise, the fixed-effects

model was employed.24

Subgroup analyses were carried out for the outcomes of

intra-operative complications, thrombotic complications,

infectious complications, and mechanical complications.

Available data were stratified based on patient’s age, method

of placement (puncture or surgical cut-down), whether anti-

biotic or thromboprophylaxis was applied, so as to investi-

gate whether these factors influenced the outcomes.

Sensitivity analysis was performed and only outcomes with

at least two studies were included. We performed sensitivity

analysis for high quality studies (RCT with low risk of bias

and non-randomized studies with quality score ≥8 points).

We also used funnel plots to screen potential publication bias.

A two-tailed p-value less than 0.05 was considered as statis-

tical significance, except otherwise specified.

ResultsA total of 914 possibly eligible studies were identified

from databases (Figure 1). Thirteen studies including

3,896 cases (2,176 for chest ports, and 1,720 for arm

ports) fulfilled the inclusion standard and were selected

for final evidence synthesis. Agreement with respect to

study selection between the two reviewers was 92%.

Characteristics of included studiesTable 1 depicts the characteristics of included studies in this

study. Of these included studies, two29,30 were RCTs, and

Pubmed: n=287

Studies identified throughinitial searches of electronic

databases: n=914

Embase: n=564

Titles and abstracts screened:

Duplications: n=308

Excluded studies: n=582

Excluded studies: n=11

Meeting abstracts: n=4Reviews: n=5

Clinical trial description: n=2

Irrelevant atricles: n=476Non-comparative studies: n=15Animal studies: n=1Case reports: n=90

Full-text articles screened:

Included studies:n=13

n=606

n=24

Cochrane:n=63

Figure 1 Flow diagram of study selection process.

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DovePress6101

Tab

le1Characteristicsofincludedstudies

Study

Yea

rCountry

Design

Patients

Appro

ach

forCP

Appro

ach

forAP

Antibiotic

Coag

ulation

Match

ing

Age

,

years(m

ean/

med

ian)

Ran

geCP

AP

TIVAP

Pro

phy

laxis

Pro

phy

laxis

Alahyaneetal32

2010

Morroco

RC

43

16–76

340

240

NR

NR

NR

NR

Yes

NR

Akahaneetal33

2011

Japan

RC

64

20–91

47

115

P-U

Celsite

Puncture/

ultrasound

Puncture/

radiological

None

NR

1,2,4,5,7,8,9

Biffietal29

2009

Italy

RCT

52

18–75

270

133

Bardport

Puncture/

ultrasound

Surgicalcut-

down

NR

None

1,2,4,5,6,7

D'Angelo

etal30

2002

Italy

RCT

61.5

17–75

25

25

NR

Puncture/

ultrasound

Surgicalcut-

down

NR

NR

1,2,4,7

Goltzetal34

2012

Germ

any

RC

58.8

18–88

52

152

PowerPort

Puncture/

radiological

Puncture/

radiological

Yes

NR

1,2,4,5,7,8

Goltzetal10

2013

Germ

any

PC

55.8

19–84

25

25

PowerPort/P.

A.S

Port

Puncture/

radiological

Puncture/

radiological

NR

NR

1,2,4,5,7

Kuriakose

etal35

2002

USA

RC

58

14–88

273

149

BardPort/

Meditec-

R-Port

Puncture/

NR

Puncture/

radiological

NR

Yes

1,2,4,5,6,7,9

Lietal36

2016

People's

Republic

of

China

RC

53.6

NR

237

107

Bardport

Puncture/

direct

Puncture/

ultrasound

NR

NR

1,2,4,5,7

Marcy

etal37

2005

France

RC

55.7

NR

100

100

Bard/

BraunMedical

Surgicalcut-

down

Puncture/

radiological

None

NR

1,2,4,5,7,8

Marcy

etal38

2008

France

RC

59

20–83

112

113

Bard/

BraunMedical

Surgicalcut-

down

Puncture/

radiological

None

None

1,2,4,5,7,8,9

Matiotti-Neto

etal39

2017

USA

RC

NR

NR

247

195

NR

Puncture/

fluoroscopy

Surgicalcut-

down

NR

NR

1,2,3,4,5,6,7

Iorioetal31

2018

Italy

PC

59.5

NR

106

109

NR

Surgicalcut-

down

Surgicalcut-

down

Yes

NR

1,2,4,5,6,7,8

Shionoetal40

2014

Japan

RC

62.9

NR

342

257

BardX-Port/

Slim

Port

Puncture/

fluoroscopy

Puncture/

fluoroscopy

Yes

NR

1,2,4,5,7,8

Notes:

Matchingcriteria:1=age;2=sex;3=bodymassindex;4=TIVAPprocedure;5=primarymalignancy;6=sideofplacement;7=singlesurgicalorradiologist

team

;8=antibiotics

description;9=coagulationdescription.

Abbreviations:

RC,retrospectivecohort;PC,prospectivecohort;RCT,randomizedcontrolledtrial;CP,chest

port;AP,arm

port;NR,notreported;TIVAP,totally

implantable

venousaccess

port.

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DovePressCancer Management and Research 2019:116102

two10,31 were prospective non-randomized cohort studies.

The remaining studies32-40 were retrospective. As for indica-

tions, the majority of included studies were about cancer

patients with upcoming chemotherapies, and most of the

reported studies used commercial venous port devices

(BardPort, PowerPort, P-U Celsite, BraunMedical, and

Meditec-R-Port). For port implantation, the majority of stu-

dies used percutaneous puncture approach, while there were

three studies31,37,38 and four studies29,31,39 which used direct

surgical cut-down methods to implant chest port devices and

arm port devices, respectively.

Based on Cochrane Handbook for Systematic Reviews

of Interventions,24 Table 2 summarizes the risk of bias of

two included RCTs, one RCT was considered as moderate

risk, while the other p< was regarded as low risk. In Table

3, risk of bias analysis of the remaining included studies

was summarized in line with the NOS.25 Among these

non-randomized studies, two32,39 had a quality score

below seven, and the remaining studies were considered

as high-quality.

Primary outcomesThe pooled data from 13 studies10,29–40 that evaluated

primary outcomes in 3,896 patients (Figure 2) revealed

no significant differences for total complication events

between the chest port and arm port groups (11.8% and

12.8%; OR 0.94, 95% CI 0.77–1.15; p=0.53). Eleven

studies in which 3,266 patients were included thoroughly

reported the incidences of intra-operative complications,

thrombotic complications, infectious complications, and

mechanical complications. For procedure-related infec-

tions, no statistically significant differences were observed

between the chest port and arm port groups (3.15% and

3.37%; OR 1.11, 95% CI 0.74–1.66; p=0.63). Differences

for procedure-related thrombotic complications and

mechanical complications were also absent between the

two groups (2.87% and 3.91%; OR 0.75, 95% CI

0.49–1.13; p=0.17; and 4.86% and 2.96%; OR 1.34, 95%

CI 0.92–1.95; p=0.13, respectively). However, when

comparing the difference for intra-operative complica-

tions, the incidence in chest port group was significantly

higher (1.38% and 0.41%; OR 2.38, 95% CI 1.07–5.29;

p=0.03) (Figure 3).

Secondary outcomesData on procedure conversion rate were obtained in six

studies,26,29,31,38–40 which assessed 1,314 and 914 patients in

chest port group and arm port group, respectively. The proce-

dure conversion rate was significantly higher in arm port group

than that in chest port group (2.51% in chest port group and

8.32% in arm port group; OR 0.27, 95% CI 0.15–0.46;

p<0.001) (Figure 4A). When incidences of early port removal

were analyzed, there were three studies29,36,39 including 1,189

patients evaluated, and no significant difference was present

between groups (7.29% and 4.37%; OR 1.27, 95% CI

0.26–6.19; p=0.77) (Figure 4A). As for operating time, three

studies including 707 patients were reported, however, one

study30 presented operating time as “mean ± standard devia-

tion”, one study39 presented as “mean and range”, and the last

one31 displayed as “mean and interquartile range”. Using

Hozo’s26 method, ranges were converted to estimated SD for

further comparison.41 Result of the analysis of operating time

revealed that there were no statistically significant differences

between chest port group and arm port group (WMD −4.31;95% CI −17.81–9.19; p=0.53), with high between-study het-

erogeneity (I2=0.98, p<0.01) (Figure 4B).

Subgroup analysisIn subgroup analysis of antibiotic prophylaxis, there were

no statistically significant differences with respect to infec-

tion rate in comparison of the previous results, suggesting

that prophylactic administration of antibiotics did not

interfere with procedure-related infection rate (Table 4).

Three studies29,35,38 reported the anticoagulant profiles,

and results showed that thromboprophylaxis did not influ-

ence the risk for thrombosis either. In the subgroup analy-

sis of insertion methods, only one study31 used surgical

cut-down approach in all patients, and six studies10,33–36,40

Table 2 Risk of bias of included randomized controlled trials based on Cochrane Handbook for Systematic Reviews of Interventions

Study Sequence

generation

Allocation

concealment

Blinding Incomplete

outcome data

Selective out-

come reporting

Other

sources of

bias

Risk of

bias

D'Angelo et al, 200230 Yes Uncertain Uncertain Yes Yes Yes Moderate

Biffi et al, 200929 Yes Yes Uncertain Yes Yes Yes Low

Notes: Low risk: 5–6 sections with “yes”; moderate risk: 3–4 sections with “yes”; high risk: ≤2 sections with “yes”.

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DovePress6103

employed puncture approach for all patients. The results

did not change the conclusions for the primary outcomes

from original analyses, and pooled data from six studies

including 1,781 patients who underwent percutaneous

puncture approach indicated consistent results showing

that the incidences of intra-operative events in chest port

group were significantly higher (2.05% and 0.12%, OR

7.87, 95% CI 1.82–34.13; p<0.01) (Table 4). Finally, two

subgroups were stratified according to patients’ age group

(<60 years old and ≥60 years old). After pooling data from

eight studies including 2,063 patients less than 60 years

old, the result showed that no significant difference was

detected with regard to intra-operative events between

chest ports and arm ports (1.19% and 0.02%, OR 2.59,

95% CI 0.74–9.08; p<0.14), suggesting that age may be

a risk factor for intra-operative events (Table 4).

Sensitivity analysis and publication biasOne low risk RCT29 and six non-randomized comparative

studies10,33,35–38 that scored over eight points according to

NOS were included in the sensitivity analysis. The results

of sensitivity analysis did not change the conclusions for

total complication events, all of the primary outcomes, and

incidence of procedure conversion from original analyses.

However, between-study heterogeneity decreased slightly

in all of these parameters (Table 5). Due to insufficient

data, sensitivity analyses for early port removal and oper-

ating time were not performed.

Figure 5 depicts a funnel plot of included studies that

assessed primary outcomes of interest. The distribution was

even and around the vertical. Most of the studies were within

the 95% CIs, suggesting no apparent publication bias.

DiscussionThis systematic review with meta-analysis compared the

clinical efficacy of two types of TIVAPs: chest port and

arm port. Our results showed that arm port is a safe site for

implantation, with lower incidence of intra-operative com-

plications, however, arm port is associated with higher

procedure conversion rate. No statistically significant dif-

ferences between chest port and arm port were found in

total complication events, procedure-related infections,

procedure-related thrombotic complications, incidence of

early port removal, and operating duration. On subgroup

analysis, we found that antibiotic prophylaxis and method

of insertion did not interfere with the conclusions for the

primary outcomes from original analyses, but results

revealed that there were no statistically significantTab

le3Riskofbiasforincludednon-randomizedstudiesbasedonNewcastle-O

ttaw

ascale

Study

Rep

resentative

ness

oftheex

posed

cohort

Selec

tion

ofthe

non-

exposed

cohort

Ascertainmen

t

ofex

posu

re

Dem

onstrationthat

outcomeofinterest

was

notpresentat

startofstudy

Comparab

ility

ofco

hortson

thebasis

ofthe

designor

analysis

Assessm

ent

ofoutcome

Was

follo

w-

uplong

enough

for

outcomes

to

occur

Adeq

uac

y

offollo

w-

upof

cohorts

Quality

score

Alahyaneetal,201032

11

01

21

00

6

Akahaneetal,201133

11

11

21

11

9

Goltzetal,201234

11

11

21

00

7

Goltzetal,201310

11

11

21

11

9

Kuriakose

etal,200235

11

11

21

10

8

Lietal,201636

11

11

21

11

9

Marcy

etal,200537

11

11

21

11

9

Marcy

etal,200838

11

11

21

10

8

Matiotti-Neto

etal,201739

11

11

11

00

6

Iorioetal,201831

11

11

21

00

7

Shionoetal,201440

11

11

21

00

7

Notes:Qualityofobservationalstudyisassessedaccordingto

Newcastle-O

ttaw

ascale(N

OS),consistingofthreecomponents:patientselection(4

points),comparability

ofthestudygroups(2

points)andassessmentofoutcome(3

points).

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DovePressCancer Management and Research 2019:116104

differences in intra-operative events in those patients under

60, suggesting that age may affect the risk for intra-

operative complications. Sensitivity analysis did not

change the conclusions of all endpoints of interest.

For the utilization of a new technique, patients’ safety

is always the first priority. Chest ports are still popular and

their application is continuously expanding among non-

surgical physicians.15 Under the guidance of ultrasound or

fluoroscopy, the risks for intra-operative events, such as

pneumothorax, hemothorax, and arterial injury, are there-

fore minimized during percutaneous cannulations of sub-

clavian vein or jugular vein.42 Implantation of arm ports

through peripheral forearm vessels is more surgically chal-

lenging, but arm port users experience less perception of

“foreign body”, with satisfactory cosmetic results. Pooled

data from 2,176 chest port and 1,720 arm port users from

included studies of this study, showed that incidences for

total complication events were 11.8% and 12.8%, respec-

tively. Our result of total complication events is in agree-

ment with previous studies that assessed overall

complication rate,4,19,43 with no significant difference

between chest ports and arm ports. Although the technique

of implanting arm ports is newly developed, and more

challenging for clinicians, our findings indicate that arm

ports are at least as safe as conventional chest ports with

proper patient indications.

The procedure conversion rate is significantly higher for

arm ports as compared to chest ports. Additional challenges

for arm port implantation include anatomic variations,

longer distance for implantation, and frequent use of per-

ipheral intravenous access, which make cannulation of per-

ipheral forearm vessels not always achievable. Anatomic

variations of basilic, cephalic or brachial vein frequently

occur, and these peripheral vessels are much smaller in

diameter as compared with central veins. These peripheral

forearm vessels may be difficult to recognize or too limited

in size to use.44 Therapeutic usage of peripheral venous

access is frequent for oncologic and critically-ill patients,

however, frequent puncture of these vessels leads to adhe-

sion, spasm, or shrinkage, and thus complicates anatomy of

surrounding structures. Moreover, patients with conversion

might reveal higher risks for other complications. As

implantation of indwelling TIVAPs is performed not only

by surgeons, but also widely performed by non-surgical

practitioners (such as trained physicians, radiologists,

anesthesiologists, oncologists, and so forth), arm port

implantation may need to be placed in selected patients to

avoid procedure conversion. In our experience, no matter

how experienced the clinician is in arm port implantation,

preoperative ultrasound evaluation of forearm vessels is

indicated in every case to minimize this unfavorable event.

Our findings showed that chest port was associated

with higher incidence of intra-operative complications.

Due to specific anatomy, accidental pneumothorax or

arterial puncture could not be eliminated completely,

even if ultrasound or fluoroscopy guidance is routinely

available. But interestingly, in subgroup analysis, no

between-group differences in intra-operative events were

seen in those patients under 60. Patients’ age appeared to

be relevant to the risk for intra-operative events, although

it is still poorly illustrated. Similar results were previously

reported: high age is an independent risk factor for proce-

dural complications in subclavian vein puncture, and one

implication is closely related to variations in body

Figure 2 Forest plot and meta-analysis of total complication events.

Abbreviation: M-H, Mantel-Haenszel method.

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habitus.45,46 Based on our experiences, our explanation is

that vessel fragility and decreased vessel elasticity may be

responsible for this issue, as the elderly are prone to

compromised vascular compliance, which makes the

aged population more susceptible to vascular interference

and trauma. Another potential reason is higher morbidities

of chronic obstructive pulmonary diseases and obesity that

attribute to structural elevation of apex pulmonis, thereby

Figure 3 Forest plot and meta-analysis of primary outcomes.

Abbreviation: M-H, Mantel-Haenszel method.

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DovePressCancer Management and Research 2019:116106

facilitating the occurrence of pneumothorax.46 Certainly,

special caution in terms of intra-operative complications in

aged patients is alerted when performing implantation of

chest ports.

The pooled analyses of procedure-related infections,

thrombolytic complications, and mechanical complica-

tions showed no between-group differences. Subgroup

analysis of antibiotic prophylaxis demonstrated that

administration of antibiotics did not affect the outcome

of overall infection rate. But we still recommend that

anti-septic protocols should be followed for the sake of

infection prevention and management in oncologic

patients who are vulnerable to infection owing to leu-

kocytopenia induced by immune suppression.47

Subgroup analysis of thromboprophylaxis did not alter

any original conclusion, which was consistent with

Chaukiyal’s result48 showing that thromboprophylaxis

had no beneficial effects on the risks of catheter-

related thrombolytic complications in oncologic patients.

Nonetheless, as regular heparin flushing has become

routine practice for TIVAPs in almost every

institution,49 it seems to be enough for the prevention

of port-related thrombosis.50

Two methods of implanting TIVAPs are used in current

clinical practice: surgical cut-down or percutaneous punc-

ture. No consensus has ever been reached regarding implan-

tation methods because percutaneous puncture is less time-

consuming, but surgical cut-down method lowers the risk

for complications such as pneumothorax.31 With the world-

wide spread of ultrasound monitoring for venous access,

venous surgical cut-down method is on the decrease.31 No

significant difference in terms of insertion approach could

be addressed in this study. Of the three included studies in

which operating time was reported, detailed procedure

description was not available in one study,30 one study31

inserted TIVAPs through surgical cut-down, and the last39

separately used surgical approach and puncture to cannulate

arm ports and chest ports, respectively. Because of the

heterogeneous characteristic and data insufficiency, it is

difficult to reach a definite conclusion for the comparison

of inserting methods in this instance.

Arm port implantation is especially attractive to young

females for cosmetic reasons, as it leaves no scars on the

chest. Arm port users experience less “bra inconvenience”,

and psychologically, patients’ anxiety of indwelling arm

ports might be less as compared to chest ports.40

Figure 4 Forest plot and meta-analysis of secondary outcomes. (A) Comparison of procedure conversion rate and early port removal. (B) Comparison of operating time

between groups.

Abbreviations: M-H, Mantel-Haenszel method; IV, inverse variance method.

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Tab

le4Subgroupanalysiscomparingchest

portsandarm

ports

Gro

up

Pro

cedure-related

infections

Pro

cedure-related

thro

mbotic

complic

ations

Intra-operativeev

ents

Mec

han

ical

complic

ations

nOR(95%

CI)

I2 (%)

Heteroge

neity

nOR(95%

CI)

I2 (%)

Heteroge

neity

nOR(95%

CI)

I2 (%)

Heteroge

neity

nOR(95%

CI)

I2 (%)

Heteroge

neity

Ove

rall

11

1.11

(0.74–1.66)

00.59

11

0.75

(0.49–1.13)

28

0.19

11

2.38

(1.07–5.29)

36

0.17

11

1.34

(0.92–1.95)

25

0.21

Antibiotic

pro

phy

laxis

Yes

31.12

(0.56–2.24)

00.74

N/A

N/A

N/A

No

31.24

(0.55–2.76)

00.52

N/A

N/A

N/A

Anti-coag

ulant

pro

phy

laxis

Yes

N/A

10.91

(0.21–3.85)

N/

A

N/A

N/A

N/A

No

N/A

20.54

(0.12–2.32)

74

0.05

N/A

N/A

Methodof

insertion

Surgicalcut-down

10.51

(0.05–5.70)

N/

A

N/A

13.11

(0.13–77.29)

N/

A

N/A

10

N/

A

N/A

10

N/

A

N/A

Puncture

61.03

(0.63–1.68)

00.51

60.81

(0.42–1.56)

19

0.29

67.87

(1.82–34.13)

00.93

61.55

(0.98–2.47)

38

0.15

Age

<60yearsold

80.90

(0.54–1.52)

00.6

80.78

(0.50–1.23)

35

0.15

82.59

(0.74–9.08)

44

0.17

81.14

(0.75–1.74)

00.51

>60yearsold

21.25

(0.61–2.54)

00.8

21.00

(0.22–4.52)

N/

A

N/A

29.81

(1.13–85.37)

00.84

21.47

(0.03–71.26)

79

0.03

Abbreviations:

n,numberofstudies;N/A,notapplicable.

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DovePressCancer Management and Research 2019:116108

Moreover, arm port is especially appropriate for patients

who require neck or chest radiation therapies.40

Comparison of these quality-of-life related outcomes is

of importance, however, only a limited number of studies

reported these parameters, which were measured based on

various evaluating methods, such as self-administered

questionnaire10,36 and quality of life score,37,46 and non-

uniformity of these measurements made these data incom-

parable in this study.

Our study is distinctive and provides valuable informa-

tion to oncology-related clinicians in that, to the best of our

knowledge, this systematic review with meta-analysis is the

first one to comprehensively investigate the clinical efficacies

and represents the most up-to-date information with respect

to chest ports and arm ports. We used multiple strategies to

launch evidence acquisition, strict standards to assess quality

of included studies, scientific statistics for data analysis,

subgroup and sensitivity analysis to control study heteroge-

neity. Our study has several limitations which should be

taken into consideration. First of all, the most apparent lim-

itation of the present study is that most of the included data

were from retrospective cohort studies. Inadequacy of rando-

mization and lack of blinding will increase the risk of bias.

Secondly, this study was based on the premised assumption

that demographic subgroups (age, sex, race, nationality, and

disease distribution) were similar enough for comparison.

However, subgroup analysis with regard to age generated

some different outcomes, hence, further systematic reviews

should be conducted when sufficient future results are

released. And then, the included studies were from different

institutions with various levels of clinician expertise. Not

only the between-study time-span, which is more than 10

Table 5 Sensitivity analysis comparing chest ports and arm ports

Outcome of interest Number

of studies

Number of chest

port patients

Number of arm

port patients

OR (95%CI) p-value I2

(%)

Heterogeneity

Total complication events 7 1,064 742 0.88 (0.67–1.17) 0.38 41 0.12

Procedure-related

infections

7 1,064 742 0.95 (0.56–1.62) 0.86 0 0.49

Procedure-related

thrombotic complications

7 1,064 742 0.92 (0.56–1.51) 0.74 34 0.18

Intra-operative events 7 1,064 742 3.28 (1.03–10.40) 0.04 33 0.21

Mechanical complications 7 1,064 742 1.06 (0.71–1.58) 0.79 0 0.52

Conversion rate 3 619 353 0.33 (0.19–0.57) <0.001 0 0.44

Figure 5 Funnel plot demonstrating meta-analysis of primary outcomes of interest.

Abbreviation: SE, standard error.

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DovePress6109

years, but also the different backgrounds of the TIVAP

operators with different insertion approaches will affect the

outcomes of interest. Next, some outcomes of interest, espe-

cially the mechanical complications, might not be clearly

defined in some studies, yielding misinterpretation of results

or data omission. So, the incidence of mechanical complica-

tions might be underrated, and caution should be taken when

interpreting results of this section. Finally, follow-up period

of included studies was generally short. But there are increas-

ing cumulative risks for TIVAP-related infection, thrombo-

sis, and mechanical mis-functioning along with the duration

of port indwelling, some incidences of outcomes might be

underestimated because of insufficient follow-up period.

Surely, long-term outcomes of arm ports, especially for

oncologic efficacy and safety, require further investigation.

ConclusionIn this systematic review with meta-analysis that

compared clinical efficacy of two types of TIVAPs: chest

port and arm port, we found that arm port is associated with

higher procedure conversion rate, but lower incidence of intra-

operative complications. There are no statistically significant

differences between chest port and arm port with regard to in

total complication events, procedure-related infections, proce-

dure-related thrombotic complications, incidence of early port

removal, and operating duration. Age may be a risk factor for

intra-operative complications. Further confirmation of these

results is warranted and our findings should be updated with

larger scale and well-designed studies with longer follow-up.

AcknowledgmentThis study received no specific grant from any funding

agency.

DisclosureThe authors report no conflicts of interest in this work.

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